National trends in the endovascular and surgical treatment of idiopathic intracranial hypertension

BACKGROUND

The pattern of surgical treatments for Idiopathic Intracranial Hypertension (IIH) in the United States is not well-studied, specifically the trend of utilizing endovascular venous stenting (EVS) as an emerging technique.

METHODS

In this cross-sectional study, we aimed to explore the national trend of utilizing different procedures for the treatment of IIH including EVS, Optic Nerve Sheath Fenestration (ONSF), and CSF Shunting, with a focus on novel endovascular procedures. Moreover, we explored rates of 90-day readmission and length of hospital stay following different procedures, besides the effects of sociodemographic and clinical parameters on procedure choice.

RESULTS

36,437 IIH patients were identified from records between 2010 and 2018. Those in the EVS group were 29 years old on average, and 93.4 % were female. Large academic hospital setting was independently associated with higher EVS utilization, while other factors were not predictive of procedure choice. The proportion of EVS use in IIH hospitalizations increased significantly from 2010 to 2018 (P < 0.001), while there was a relative decline in the frequency of shunting procedures (P = 0.001), with ONSF utilization remaining stable (P = 0.39). The rate of 90-day readmission and length of hospital stay were considerably lower following EVS compared to other procedures (Ps < 0.001).

CONCLUSION

This study presents novel population-level data on national trends in the frequency and outcome of EVS for IIH therapy. EVS was associated with shorter length of hospital stays and fewer readmission rates. In addition, a continuous increase in venous stenting compared to other procedures suggests an increasing role for endovascular therapies in IIH.

Plateauing atrial fibrillation burden in acute ischemic stroke admissions in the United States from 2010 to 2020

BACKGROUND

Utilization of oral anticoagulants for acute ischemic stroke (AIS) prevention in patients with atrial fibrillation (AF) increased in the United States over the last decade. Whether this increase has been accompanied by any change in AF prevalence in AIS at the population level remains unknown. The aim of this study is to evaluate trends in AF prevalence in AIS hospitalizations in various age, sex, and racial subgroups over the last decade.

METHODS

We used data contained in the 2010-2020 National Inpatient Sample to conduct a serial cross-sectional study. Primary AIS hospitalizations with and without comorbid AF were identified using International Classification of Diseases Codes. Joinpoint regression was used to compute annualized percentage change (APC) in prevalence and to identify points of change in prevalence over time.

RESULTS

Of 5,190,148 weighted primary AIS hospitalizations over the study period, 25.1% had comorbid AF. The age- and sex-standardized prevalence of AF in AIS hospitalizations increased across the entire study period 2010-2020 (average APC: 1.3%, 95% confidence interval (CI): 0.8-1.7%). Joinpoint regression showed that prevalence increased in the period 2010-2015 (APC: 2.8%, 95% CI: 1.9-3.9%) but remained stable in the period 2015-2020 (APC: -0.3%, 95% CI: -1.0 to 1.9%). Upon stratification by age and sex, prevalence increased in all age/sex groups from 2010 to 2015 and continued to increase throughout the entire study period in hospitalizations in men 18-39 years (APC: 4.0%, 95% CI: 0.2-7.9%), men 40-59 years (APC: 3.4%, 95% CI: 1.9-4.9%) and women 40-59 years (APC: 4.4%, 95% CI: 2.0-6.8%). In contrast, prevalence declined in hospitalizations in women 60-79 (APC: -1.0%, 95% CI: -0.5 to -1.5%) and women ⩾ 80 years over the period 2015-2020 but plateaued in hospitalizations in similar-aged men over the same period.

CONCLUSION

AF prevalence in AIS hospitalizations in the United States increased over the period 2010-2015, then plateaued over the period 2015-2020 due to declining prevalence in hospitalizations in women ⩾ 60 years and plateauing prevalence in hospitalizations in men ⩾ 60 years.

Demographic Disparities in the Incidence, Clinical Characteristics, and Outcome of Posterior Reversible Encephalopathy Syndrome in the United States

OBJECTIVES

To estimate age-specific, sex-specific, and race-specific incidence of posterior reversible encephalopathy syndrome (PRES) in the United States.

METHODS

We conducted a retrospective cohort study using the State Inpatient Database of Florida (2016-2019), Maryland (2016-2019), and New York (2016-2018). All new cases of PRES in adults (18 years or older) were combined with Census data to compute incidence. We evaluated the generalizability of incident estimates to the entire country using the 2016-2019 National Readmissions Database (NRD).

RESULTS

Across the study period, there were 3,716 incident hospitalizations for PRES in the selected states. The age-standardized and sex-standardized incidence of PRES was 2.7 (95% CI 2.5-2.8) cases/100,000/y. Incidence in female patients was >2 times that of male patients (3.7 vs 1.6 cases/100,000/y, p < 0.001). Incidence increased with age in both sexes (p-trend <0.001). Similar demographic distribution of first hospitalization for PRES was also noted in the entire country using the NRD. Age-standardized and sex-standardized PRES incidence in Black patients (4.2/100,000/y) was significantly greater than in Non-Hispanic White (2.7/100,000/y) and Hispanic patients (1.2/100,000/y) (p < 0.001 for pairwise comparisons).

DISCUSSION

The incidence of PRES in the United States is approximately 3/100,000/y, but incidence in female patients is >2 times that of male patients. PRES incidence is higher in Black compared with non-Hispanic White and Hispanic patients.

Age- and Sex-Specific Trends in Medical Complications After Acute Ischemic Stroke in the United States

BACKGROUND AND OBJECTIVES

To test the hypothesis that the age and sex-specific prevalence of infectious (pneumonia, sepsis, and urinary tract infection [UTI]) and noninfectious (deep venous thrombosis [DVT], pulmonary embolism [PE], acute renal failure [ARF], acute myocardial infarction [AMI], and gastrointestinal bleeding [GIB]) complications increased after acute ischemic stroke (AIS) hospitalization in the United States from 2007 to 2019.

METHODS

We conducted a serial cross-sectional study using the 2007-2019 National Inpatient Sample. Primary AIS admissions in adults (aged 18 years or older) with and without complications were identified using International Classification of Diseases codes. We quantified the age/sex-specific prevalence of complications and used negative binomial regression models to evaluate trends over time.

RESULTS

Of 5,751,601 weighted admissions, 51.4% were women. 25.1% had at least 1 complication. UTI (11.8%), ARF (10.1%), pneumonia (3.2%), and AMI (2.5%) were the most common complications, while sepsis (1.7%), GIB (1.1%), DVT (1.2%), and PE (0.5%) were the least prevalent. Marked disparity in complication risk existed by age/sex (UTI: men 18-39 years 2.1%; women 80 years or older 22.5%). Prevalence of UTI (12.9%-9.7%) and pneumonia (3.8%-2.7%) declined, but that of ARF increased by ≈3-fold (4.8%-14%) over the period 2007-2019 (all p < 0.001). AMI (1.9%-3.1%), DVT (1.0%-1.4%), and PE (0.3%-0.8%) prevalence also increased (p < 0.001), but that of sepsis and GIB remained unchanged over time. After multivariable adjustment, risk of all complications increased with increasing NIH Stroke Scale (pneumonia: prevalence rate ratio [PRR] 1.03, 95% CI 1.03-1.04, for each unit increase), but IV thrombolysis was associated with a reduced risk of all complications (pneumonia: PRR 0.80, 85% CI 0.73-0.88; AMI: PRR 0.85, 95% CI 0.78-0.92; and DVT PRR 0.87, 95% CI 0.78-0.98). Mechanical thrombectomy was associated with a reduced risk of UTI, sepsis, and ARF, but DVT and PE were more prevalent in MT hospitalizations compared with those without. All complications except UTI were associated with an increased risk of in-hospital mortality (sepsis: PRR 1.97, 95% CI 1.78-2.19).

DISCUSSION

Infectious complications declined, but noninfectious complications increased after AIS admissions in the United States in the last decade. Utilization of IV thrombolysis is associated with a reduced risk of all complications.

Collaterals and Elusive Ischemic Penumbra

As alternative blood supply routes, collateral blood vessels can play a crucial role in determining patient outcomes in acute and chronic intracranial occlusive diseases. Studies have shown that increased collateral circulation can improve functional outcomes and reduce mortality, particularly in those who are not eligible for reperfusion therapy. This article aims to discuss the anatomy and physiology of collateral circulation, describe current imaging tools used to measure collateral circulation, and identify the factors that influence collateral status.

Trends in the Incidence of Spontaneous Subarachnoid Hemorrhages in the United States, 2007-2017

BACKGROUND AND OBJECTIVE

To test the hypothesis that age-specific, sex-specific, and race-specific and ethnicity-specific incidence of nontraumatic subarachnoid hemorrhage (SAH) increased in the United States over the last decade.

METHODS

In this retrospective cohort study, validated International Classification of Diseases codes were used to identify all new cases of SAH (n = 39,475) in the State Inpatients Databases of New York and Florida (2007-2017). SAH counts were combined with Census data to calculate incidence. Joinpoint regression was used to compute the annual percentage change (APC) in incidence and to compare trends over time between demographic subgroups.

RESULTS

Across the study period, the average annual age-standardized/sex-standardized incidence of SAH in cases per 100,000 population was 11.4, but incidence was significantly higher in women (13.1) compared with that in men (9.6), p < 0.001. Incidence also increased with age in both sexes (men aged 20-44 years: 3.6; men aged 65 years or older: 22.0). Age-standardized and sex-standardized incidence was greater in Black patients (15.4) compared with that in non-Hispanic White (NHW) patients (9.9) and other races and ethnicities, p < 0.001. On joinpoint regression, incidence increased over time (APC 0.7%, p < 0.001), but most of this increase occurred in men aged 45-64 years (APC 1.1%, p = 0.006), men aged 65 years or older (APC 2.3%, p < 0.001), and women aged 65 years or older (APC 0.7%, p = 0.009). Incidence in women aged 20-44 years declined (APC -0.7%, p = 0.017), while those in other age/sex groups remained unchanged over time. Incidence increased in Black patients (APC 1.8%, p = 0.014), whereas that in Asian, Hispanic, and NHW patients did not change significantly over time.

DISCUSSION

Nontraumatic SAH incidence in the United States increased over the last decade predominantly in middle-aged men and elderly men and women. Incidence is disproportionately higher and increasing in Black patients, whereas that in other races and ethnicities did not change significantly over time.

Contemporary Incidence and Burden of Cerebral Venous Sinus Thrombosis in Children of the United States

Background:

The incidence of cerebral venous thrombosis (CVT) in children of the United States is unknown, and it is uncertain how the burden of CVT hospitalizations in children changed over the last decade.

Methods:

We conducted a retrospective cohort study using the State Inpatient Database and Kid’s inpatient database. All new CVT cases in children (0–19 years) in the New York 2006 to 2018 State Inpatient Database (n=705), and all cases of CVT in the entire US contained in the 2006 to 2019 Kid’s inpatient database (weighted n=6115) were identified using validated International Classification of Diseases (ICDs ) codes. Incident counts were combined with census data to compute incidence. Between-group differences in incidence were tested using 2-proportions Z -test, and Joinpoint regression was used to trend incidence over time.

Results:

Across the study period, 48.2% of all incident CVT cases and 44.6% of all CVT admissions nationally were in girls. Of all incident cases, 27.2% were infants and 65.8% of these infants were neonates. Average incidence across the study period was (1.1/100 000/year, SE:0.04) but incidence in infants (6.4/100 000/year) was at least 5 times the incidence in other age groups (1–4 years: 0.7/100 000/year, 15–19 years: 1.2/100 000/year). Incidence and national burden of CVT admissions was higher in girls in adolescents 15 to 19 years, but overall burden was higher in boys in other age groups. Age- and sex-standardized CVT incidence increased by 3.8% annually (95% CI, 0.2%–7.6%), while the overall burden of admissions increased by 4.9% annually (95% CI, 3.6%–6.2%).

Conclusions:

CVT incidence in New York and national burden of CVT increased significantly over the last decade.

Trends in age and sex-specific prevalence of cancer and cancer subtypes in acute ischemic stroke from 2007-2019

OBJECTIVE

To describe age and sex-specific prevalence of cancer in acute ischemic stroke (AIS) hospitalizations in the United States over the last decade.

METHODS

We conducted a retrospective serial cross-sectional study using all primary AIS discharges (weighted n=5,748,358) with and without cancer in the 2007-2019 National Inpatient Sample. Admissions with primary central nervous system cancers were excluded. Joinpoint regression was used to compute the average annualized percentage change (AAPC) in cancer prevalence over time.

RESULTS

Across the study period, 12.7% of AIS admissions had previous/active cancer, while 4.4% had active cancer. Of these, 18.8% were hematologic cancers, 47.2% were solid cancers without metastasis and 34.0% were metastatic cancers of any type. Age-adjusted active cancer prevalence differed by sex (males:4.8%; females:4.0%) and increased with age up to age 70-79 years (30-39 years 1.4%; 70-79 years:5.7%). Amongst cancer admissions, lung (18.7%) and prostate (17.8%) were the most common solid cancers in men, while lung (19.6%) and breast (13.7%) were the most prevalent in women. Active cancer prevalence increased over time (AAPC 1.7%, p<0.05) but the pace of increase was significantly faster in women (AAPC 2.8%) compared to men (AAPC 1.1%) (p-comparison =0.003). Fastest pace of increased prevalence was seen for genitourinary cancers in women and for gastrointestinal cancers in both sexes. Genitourinary cancers in men declined over time (AAPC -2.5%, p<0.05). Lung cancer prevalence increased in women (AAPC 1.8%, p<0.05) but remained constant in men. Prevalence of head/neck, skin/bone, gastrointestinal, hematological and metastatic cancers increased over time at similar pace in both sexes.

CONCLUSION

Prevalence of cancer in AIS admissions increased in the US over the last decade but the pace of this increase was faster in women compared to men. Gastrointestinal cancers in both sexes and genitourinary cancers in women are increasing at the fastest pace. Additional studies are needed to determine whether this increase is from co-occurrence or causation of AIS by cancer.

Interventional compared with medical management of symptomatic carotid web: A systematic review

BACKGROUND

Carotid web (CaW) is non-atheromatous, shelf-like intraluminal projection, generally affecting the posterolateral wall of the proximal internal carotid artery, and associated with embolic stroke, particularly in younger patients without traditional stroke risk factors. Treatment options for symptomatic CaWs include interventional therapy with carotid endarterectomy or carotid stenting versus medical therapy with antiplatelet or anticoagulants. As safety and efficacy of these approaches have been incompletely delineated in small-to-moderate case series, we performed a systematic review of outcomes with interventional and medical management.

METHODS

Systematic literature search was conducted and data analyzed per PRISMA guidelines (Preferred Reporting Items for Systemic Reviews and Meta-Analyses) from January 2000 to October 2021 using the search strategy: "Carotid web" OR "Carotid shelf" OR "Web vessels" OR "Intraluminal web". Patient-level demographics, stroke risk factors, technical procedure details, medical and interventional management strategies were abstracted across 15 series. All data were analyzed using descriptive statistics.

RESULTS

Among a total of symptomatic 282 CaW patients across 14 series, age was 49.5 (44-55.7) years, 61.7% were women, and 76.6% were black. Traditional stroke risk factors were less frequent than the other stroke causes, including hypertension in 28.6%, hyperlipidemia 14.6%, DM 7.0%, and smoking 19.8%. Thrombus adherent to CaW was detected on initial imaging in 16.2%. Among 289 symptomatic CaWs across 15 series, interventional management was pursued in 151 (52.2%), carotid artery stenting in 87, and carotid endarterectomy in 64; medical management was pursued in 138 (47.8%), including antiplatelet therapy in 80.4% and anticoagulants in 11.6%. Interventional and medical patients were similar in baseline characteristics. The reported time from index stroke to carotid revascularization was median 14 days (IQR 9.5-44). In the interventional group, no periprocedural mortality was noted, major periprocedural complications occurred in 1/151 (0.5%), and no recurrent ischemic events were observed over follow-up range of 3-60 months. In the medical group, over a follow-up of 2-55 months, the recurrence cerebral ischemia rate was 26.8%.

CONCLUSION

Cumulative evidence from multiple series suggests that carotid revascularization is a safe and effective option for preventing recurrent ischemic events in patients with symptomatic carotid webs.

Cardiac arrest in spontaneous subarachnoid hemorrhage and associated outcomes

OBJECTIVE

The authors sought to analyze a large, publicly available, nationwide hospital database to further elucidate the impact of cardiopulmonary arrest (CA) in association with subarachnoid hemorrhage (SAH) on short-term outcomes of mortality and discharge disposition.

METHODS

This retrospective cohort study was conducted by analyzing de-identified data from the National (Nationwide) Inpatient Sample (NIS). The publicly available NIS database represents a 20% stratified sample of all discharges and is powered to estimate 95% of all inpatient care delivered across hospitals in the US. A total of 170,869 patients were identified as having been hospitalized due to nontraumatic SAH from 2008 to 2014.

RESULTS

A total of 5415 patients (3.2%) were hospitalized with an admission diagnosis of CA in association with SAH. Independent risk factors for CA included a higher Charlson Comorbidity Index score, hospitalization in a small or nonteaching hospital, and a Medicaid or self-pay payor status. Compared with patients with SAH and not CA, patients with CA-SAH had a higher mean NIS Subarachnoid Severity Score (SSS) ± SD (1.67 ± 0.03 vs 1.13 ± 0.01, p < 0.0001) and a vastly higher mortality rate (82.1% vs 18.4%, p < 0.0001). In a multivariable model, age, NIS-SSS, and CA all remained significant independent predictors of mortality. Approximately 18% of patients with CA-SAH survived and were discharged to a rehabilitation facility or home with health services, outcomes that were most predicted by chronic disease processes and large teaching hospital status.

CONCLUSIONS

In the largest study of its kind, CA at onset was found to complicate roughly 3% of spontaneous SAH cases and was associated with extremely high mortality. Despite this, survival can still be expected in approximately 18% of patients.

Ischemic Stroke and Pulmonary Arteriovenous Malformations: A Review

The potential of covert pulmonary arteriovenous malformations (PAVMs) to cause early onset, preventable ischemic strokes is not well known to neurologists. This is evident by their lack of mention in serial American Heart Association/American Stroke Association (AHA/ASA) Guidelines and the single case report biased literature of recent years. We performed PubMed and Cochrane database searches for major studies on ischemic stroke and PAVMs published from January 1, 1974, through April 3, 2021. This identified 24 major observational studies, 3 societal guidelines, 1 nationwide analysis, 3 systematic reviews, 21 other review/opinion articles, and 18 recent (2017-2021) case reports/series that were synthesized. Key points are that patients with PAVMs have ischemic stroke a decade earlier than routine stroke, losing 9 extra healthy life-years per patient in the recent US nationwide analysis (2005-2014). Large-scale thoracic CT screens of the general population in Japan estimate PAVM prevalence to be 38/100,000 (95% confidence interval 18-76), with ischemic stroke rates exceeding 10% across PAVM series dating back to the 1950s, with most PAVMs remaining undiagnosed until the time of clinical stroke. Notably, the rate of PAVM diagnoses doubled in US ischemic stroke hospitalizations between 2005 and 2014. The burden of silent cerebral infarction approximates to twice that of clinical stroke. More than 80% of patients have underlying hereditary hemorrhagic telangiectasia. The predominant stroke mechanism is paradoxical embolization of platelet-rich emboli, with iron deficiency emerging as a modifiable risk factor. PAVM-related ischemic strokes may be cortical or subcortical, but very rarely cause proximal large vessel occlusions. Single antiplatelet therapy may be effective for secondary stroke prophylaxis, with dual antiplatelet or anticoagulation therapy requiring nuanced risk-benefit analysis given their risk of aggravating iron deficiency. This review summarizes the ischemic stroke burden from PAVMs, the implicative pathophysiology, and relevant diagnostic and treatment overviews to facilitate future incorporation into AHA/ASA guidelines.

Abstract 136: Long-term Impact Of Aruba Trial On Management And Outcomes Of Unruptured Intracranial Arteriovenous Malformations

Introduction: The real-world evolution of management and outcomes of patients with unruptured cerebral arteriovenous malformations (AVMs) has not been well-delineated following the ARUBA trial findings of no general advantage of initial interventional (surgical/endovascular/radiotherapy) vs initial conservative medical therapy.

Methods: We analyzed from 2009-2018 the National Inpatient Sample of all AVM admissions in the United States. Analyses were performed by year and for the dichotomized periods of pre-ARUBA (2009-2013) vs. post-ARUBA (2014-2018). Joinpoint regression models with permutation model selection delineated yearly trends in intervention rate in uAVMs.

Results: Among a total of 72,812 uAVMs, 35,420 were in the post-ARUBA and 37,392 in the pre-ARUBA period. Median age was 53.3 in post-ARUBA vs. 51.8 in the pre-ARUBA period (p=0.001) with no difference in female sex, 51.1% vs. 51.8% (p=0.44). The intervention rate was lower in the post- vs -pre-ARUBA period, 29.6% vs. 34.0% (p=0.006) (figure). Interventional rate decreased monotonically by -4.32% in the post-ARUBA period (figure). Among the post-ARUBA AVM patients, compared with pre-ARUBA, there were no differences in odds of in-hospital ischemic stroke [OR 1.05 (0.92-1.20), p=0.45] or in-hospital mortality [OR 0.88 (0.62-1.24), p=0.47] but the odds did increase for combined discharge to a facility or in-hospital mortality [OR 1.14 (1.02-1.28), p=0.020]. In addition, the frequency of admissions for ruptured AVMs accelerated in the post-ARUBA period (figure).

Conclusion: Nationwide practice in management of unruptured AVMs changed substantially with the publication of the ARUBA trial, in a durable and increasing manner. Fewer admissions with interventional treatment of unruptured AVMs occurred and a corresponding increase in admission for ruptured AVMs transpired, as expected with a strategy of watchful waiting and treatment only after an index bleeding event.

Neurosyphilis presenting with a large vessel occlusion: A case report

We describe a case of a 36-year-old man who presented with stroke in the right paramedian pons in the pontine perforator territory, manifesting as intermittent headache, slurred speech, left-sided weakness, and paresthesia. This case highlights the diagnostic challenge in identifying neurosyphilis as a cause of stroke in young individuals. Clinicians should maintain vigilance for this uncommon etiology through conducting a detailed history and investigation in susceptible patients with key risk factors. Once the diagnosis was confirmed in our case, a multidisciplinary approach was used for management with neurologists, infectious disease specialists, and the neurointerventional team. Our patient ultimately underwent successful therapy with mechanical thrombectomy for basilar artery thrombosis from meningovascular syphilis.

Burden of acute symptomatic seizures in cerebral venous sinus thrombosis: A nationwide United States analysis

INTRODUCTION

Acute symptomatic seizures (ASS) are seen in one-third of cerebral venous sinus thrombosis (CVT) cases either as the presenting symptom or shortly after diagnosis in the acute phase. The goal of our study was to assess the trends in recognition of ASS in CVT over the years and to determine factors predictive of ASS in the patients with CVT for early identification of candidates who would benefit from anti-seizure medications (ASM).

MATERIALS AND METHODS

The Nationwide Inpatient Sample (NIS) database was accessed to identify adult inpatient admissions with a primary or secondary diagnosis of CVT. Comorbidities, complications, risk factors, and procedures pertaining to these hospitalizations were compared between CVT patients with and without ASS.

RESULTS

A total of 53,710 CVT-related hospitalizations were identified, of which 18.1% of patients had a burden of ASS at presentation or subsequently during hospitalization. CVT patients with ASS had a longer average duration of hospitalization and higher overall morbidity and mortality.

CONCLUSIONS

Our study showed ~one in five patients (18.1%) with CVT had ASS. ASS patients had higher odds of mortality and disability at discharge, requiring post-discharge rehabilitation care. It is crucial to identify risk factors of ASS in the CVT population to avoid future preventable revisit related to seizures. Additional research is required for risk stratification of patients with CVT for primary and secondary seizure prophylaxis and determining the appropriate choice and duration of ASM in these patients.

Causes and Predictors of 30-Day Readmission in Elderly Patients With Delirium

Objective

To study 30-day readmission (30-DR) rate and predictors for readmission among elderly patients with delirium.

Methods

This was a retrospective observational cohort study of patients aged ≥65 years with discharge diagnosis of delirium identified from the Nationwide Readmission Database using common International Classification of Diseases, Ninth Revision, and Clinical Modification codes linked to delirium diagnosis. Multivariate logistic regression analyses were performed adjusting for stratified cluster design to identify patient/system-specific factors associated with 30-DR.

Results

Overall, the 30-DR rate was 17% (7,140 of 42,655 weighted index admissions). The common causes of readmission were systemic diseases (43%), infections (27%), and neurologic diseases (18%). Compared with initial hospitalization, readmission costs were higher ($11,442 vs $10,350, p < 0.0001) with a longer length of stay (6.6 vs 6.1 days, p < 0.0001). Independent predictors of readmission included discharge against medical advice (odds ratio [OR] 1.8, p < 0.0034), length of stay (OR 1.3, p < 0.0001), and chronic systemic diseases (anemia, OR 2.4, p < 0.0001, chronic renal failure OR 1.4, p < 0.0001, congestive heart failure OR 1.3, p < 0.0001, lung disease OR 1.2, p < 0.0004, and liver disease OR 1.2, p < 0.03). Private insurance was associated with a lower risk of readmission (OR 0.78, p < 0.02).

Conclusions

The main predictors of readmission were chronic systemic diseases and discharge against medical advice. These data may help design directed clinical care pathways to optimize medical management and postdischarge care to reduce readmission rates.

Outcomes Among Patients With Reversible Cerebral Vasoconstriction Syndrome: A Nationwide United States Analysis

BACKGROUND AND PURPOSE

Reversible cerebral vasoconstriction syndrome (RCVS) is a well-established cause of stroke, but its demographics and outcomes have not been well delineated.

METHODS

Analysis of the United States Nationwide Inpatient Sample database (2016-2017) to characterize the frequency of hospitalizations for RCVS, demographic features, inpatient mortality, and discharge outcomes.

RESULTS

During the 2-year study period, 2020 patients with RCVS were admitted to Nationwide Inpatient Sample hospitals, representing 0.02 cases per 100 000 national hospitalizations. The mean age at admission was 47.6 years, with 85% under 65 years of age, and 75.5% women. Concomitant neurological diagnoses during hospitalization included ischemic stroke (17.1%), intracerebral hemorrhage (11.0%), subarachnoid hemorrhage (32.7%), seizure disorders (6.7%), and reversible brain edema (13.6%). Overall, 70% of patients were discharged home, 29.7% discharged to a rehabilitation facility or nursing home and 0.3% died before discharge. Patient features independently associated with the poor outcome of discharge to another facility or death were advanced age (odds ratio [OR], 1.04 [95% CI, 1.03-1.04]), being a woman (OR, 2.45 [1.82-3.34]), intracerebral hemorrhage (OR, 2.91 [1.96-4.31]), ischemic stroke (OR, 5.72 [4.32-7.58]), seizure disorders (OR, 2.61 [1.70-4.00]), reversible brain edema (OR, 6.26 [4.41-8.89]), atrial fibrillation (OR, 2.97 [1.83-4.81]), and chronic kidney disease (OR, 3.43 [2.19-5.36]).

CONCLUSIONS

Projected to the entire US population, >1000 patients with RCVS are hospitalized each year, with the majority being middle-aged women, and about 300 required at least some rehabilitation or nursing home care after discharge. RCVS-related inpatient mortality is rare.

Vertebral Artery Dissection in a Woman Due to Golf: An Under Recognized Etiology

INTRODUCTION

Traditionally, spontaneous cervical artery dissections have been associated with violent, sudden neck movements. These events are a significant cause of stroke related morbidity, particularly in young people. Only a handful of cases of golf-induced vertebral artery dissection (VAD) have been described, and the discussion has primarily focused on middle-aged men. Despite the discussion focused on this demographic, women are participating in golf at higher rates than ever before, and have a higher risk for developing VAD.

CASE REPORT

A 41-year-old woman presented to our hospital with sharp neck pain, dizziness, and ptosis after swinging a driver during a morning round of golf. Imaging demonstrated a right V3/V4 VAD and subsequent ischemic infarction. After administration of tissue plasminogen activator she had abrupt change in mental status with seizure-like activity. She underwent angiogram and mechanical thrombectomy, and was started in heparin 24 hours post-tissue plasminogen activator. This was subsequently changed to low-dose aspirin following thalamic petechial hemorrhage. She was discharged from the hospital after a few days with only minor deficits. We will discuss mechanism, treatment, and outcomes of VAD in context of this case.

CONCLUSION

This patient is the first woman in the literature to suffer from VAD as a result of playing golf. The twisting motion of the head and neck in a golf swing may be a risk factor for dissection and subsequent development of stroke. As a result of increased female participation in golf, we expect to see increased incidence of women presenting with "golfer's stroke" in coming years.

Ischemic Stroke in Patients With Pulmonary Arteriovenous Fistulas

BACKGROUND AND PURPOSE

Pulmonary arteriovenous fistulas (PAVFs) are a treatable cause of acute ischemic stroke (AIS), not mentioned in current American Heart/Stroke Association guidelines. PAVFs are recognized as an important complication of hereditary hemorrhagic telangiectasia.

METHODS

The prevalence of PAVF and hereditary hemorrhagic telangiectasia among patients admitted with AIS in the United States (2005-2014) was retrospectively studied, utilizing the Nationwide Inpatient Sample database. Clinical factors, morbidity, mortality, and management were compared in AIS patients with and without PAVF/hereditary hemorrhagic telangiectasia.

RESULTS

Of 4 271 910 patients admitted with AIS, 822 (0.02%) were diagnosed with PAVF. Among them, 106 of 822 (12.9%) were diagnosed with hereditary hemorrhagic telangiectasia. The prevalence of PAVF per million AIS admissions rose from 197 in 2005 to 368 in 2014 (P_trend, 0.026). Patients with PAVF were younger than AIS patients without PAVF (median age, 57.5 versus 72.5 years), had lower age-adjusted inpatient morbidity (defined as any discharge other than home; 39.6% versus 46.9%), and had lower in-hospital case fatality rates (1.8% versus 5.1%). Multivariate analyses identified the following as independent risk markers (odds ratio [95% CI]) for AIS in patients with PAVF: hypoxemia (8.4 [6.3-11.2]), pulmonary hemorrhage (7.9 [4.1-15.1]), pulmonary hypertension (4.3 [4.1-15.1]), patent foramen ovale (4.2 [3.5-5.1]), epistaxis (3.7 [2.1-6.8]), venous thrombosis (2.6 [1.9-3.6]), and iron deficiency anemia (2 [1.5-2.7]). Patients with and without PAVF received intravenous thrombolytics at a similar rate (5.9% versus 5.8%), but those with PAVF did not receive mechanical thrombectomy (0% versus 0.7%).

CONCLUSIONS

Pulmonary arteriovenous fistula-related ischemic stroke represents an important younger demographic with a unique set of stroke risk markers, including treatable conditions such as causal PAVFs and iron deficiency anemia.

Trends in hospitalizations and epidemiological characteristics of adults Moyamoya disorder in the United States

BACKGROUND AND PURPOSE

There has been an increasing prevalence of Moyamoya disorder (MMD) reported from recent US literature. There is a paucity of data available regarding trends of prevalence and epidemiological factors in the United States. To goal of this study was to test the hypotheses that racial-, sex-specific MMD hospitalizations and epidemiological factors have been increasing in the United States over the last decade.

METHODS

In this retrospective observational study, using the National Inpatient Sample (NIS) database from 2005 to 2016, MMD-related hospitalizations in patients aged ≥18 years were identified. Trends of epidemiological factors were analyzed over time using the linear regression model with the significance of differences in trend over time assessed using the Wald test. Sex- and race-specific burden of MMD were calculated using the annual US Census data. Joinpoint regression model was used to evaluate trends of hospitalizations over time.

RESULTS

A total of 24,484 adult hospitalizations were identified from January 2005 to September 2015 after excluding <18 years. Among them, approximately ~90% were aged ≤60 years, and 73.5% were females. The most common vascular and non-vascular presentations were ischemic stroke (17.3%) and seizures (21%), respectively. The trend of antithrombotic therapy has increased, while extracranial-intracranial bypass has remained stagnant. The actual average hospitalizations of MMD was 10.4 cases/ million population/year (range 4.1-17.9) and varied significantly by sex (females 14.7 [range 6.2-23.6] and males 5.9 [range 1.8-11.9]) over the 2005 to 2016 study period. The burden of hospitalizations also differed by race (African Americans 40.6 [range 32.8-63.7], Asians 24.8 [15.4-34.8], Non-Hispanic Whites 8.1 [range 6.4-11.5], and Hispanics 8.4 [2.8-12.8]) over the 2010 to 2016 study period. Joinpoint regression analysis showed an increasing overall MMD trend across the study period (+11.7%; P < 0.001), which was higher in males (+14.5% vs. +10.7%; P < 0.001). The Hispanic group had significantly increased hospitalizations over the years (+20.2%; P < 0.001).

CONCLUSION

Although overall more prevalent in females, MMD-related hospitalizations are increasing more rapidly in males. Among the racial subpopulations, African Americans had the highest MMD-related hospitalizations, even higher than Asian Americans. MMD-related hospitalizations have increased quicker in Hispanics than in any other racial group.

Recanalization of cervicocephalic artery dissection

BACKGROUND AND PURPOSE:

While there exists a substantial literature on the risk factors and clinical manifestations of cervical artery dissection (CeAD) including carotid and vertebral artery, little is known about postdissection recanalization. The goal of our study was to provide a descriptive analysis of CeAD and recanalization after dissection with neuroimaging follow up.

METHODS:

We retrospectively analyzed 51 consecutive patients with confirmed diagnoses of CeAD based on neuroimaging. Demographic data, risk factors, and dissection characteristics were recorded. Neuroimaging studies were performed at 0, 3, 6, and >6 months.

RESULTS:

Among 51 cases, the mean age of dissection (mean ± standard error) was 49.4 ± 1.92 years, and female comprised 58.8% of the patients. Extent of stenosis was 100% dissection in 37.3%, 51%–99% in 41.2%, and <51% in 21.5%. The most common presenting symptoms were headache (54.9%), neck pain (49.0%), and dizziness/gait imbalance (39.2%). The most common associated risk factors were recent history of trauma to the head and neck (41.2%) and hypertension (41.2%). In follow-up imaging, overall, 47.1% (24/51) had complete recanalization (CR), while 35.3% (18/51) did not; in the former group, 75% (18/24) recanalized completely during the first 6 months following symptom onset. A majority (84.3%) of the patients were discharged home, 15.7% were discharged to a facility, and no mortality was reported. Interestingly, location, type-/nature of dissection, and treatment did not statistically appear to influence the likelihood of recanalization.

CONCLUSIONS:

The recanalization of CeAD occurs mainly within the first 6 months after symptom onset, following which healing slows down. The study did not find an association between location, pattern, or nature of dissection on artery recanalization.

Malignant Cerebral Ischemia in A COVID-19 Infected Patient: Case Review and Histopathological Findings

Severe acute respiratory syndrome coronavirus (SARS-CoV-2) is responsible for an unprecedented worldwide pandemic that has severely impacted the United States. As the pandemic continues, a growing body of evidence suggests that infected patients may develop significant coagulopathy with resultant thromboembolic complications including deep vein thrombosis, pulmonary embolism, myocardial infarction, and ischemic stroke. However, this data is limited and comes from recent small case series and observational studies on stroke types, mechanisms, and outcomes.^1-14 Furthermore, evidence on the role of therapeutic anticoagulation in SARS-CoV-2 infected patients with elevated inflammatory markers, such as D-dimer, is also limited. We report the case of a middle-aged patient who presented with a large vessel ischemic stroke likely resulting from an underlying inflammatory response in the setting of known novel coronavirus infection (COVID-19). Histopathologic analysis of the patient's ischemic brain tissue revealed hypoxic neurons, significant edema from the underlying ischemic insult, fibrin thrombi in small vessels, and fibroid necrosis of the vascular wall without any signs of vasculature inflammation. Brain biopsy was negative for the presence of SARS-CoV-2 RNA (RT-PCR assay). Along with a growing body of literature, our case suggests that cerebrovascular thromboembolic events in COVID-19 infection may be related to acquired hypercoagulability and coagulation cascade activation due to the release of inflammatory markers and cytokines, rather than virus-induced vasculitis. Further studies to investigate the mechanism of cerebrovascular thromboembolic events and their prevention is warranted.

Abstract WMP37: Burden of Neurological Complications Among Patients With Moyamoya Disease (MMD) Treated With Revascularization

Introduction: Moyamoya disease is a chronic steno-occlusive vasculopathy involving the circle of Willis and typically presents with ischemic or hemorrhagic stroke. Prior studies suggest that either direct or indirect extracranial-intracranial bypass (EC-IC) is an effective treatment for MMD. However, the burden of post-discharge neurological complications after the procedure is unknown. Our study aims to identify the 90 readmission rate (90-DRR) and neurological complications upon readmission in revascularization and untreated MMD patients.

Method: We analyzed the data from the Nationwide Readmission Database (NRD) from 2010-2015. MMD was ascertained by ICD-9 discharge code 437.5 and revascularization (EC-IC) using 39.28. SAS 9.4 was used for data analysis with categorical and continuous variables tested using the Rao Scott Chi-square test and Student’s t-test respectively.

Result: Among total 4,902 MMD index events, 1,840 had a revascularization procedure and 3,062 did not. The 90-DRR for the treatment group was 14.72% (readmitted N=271/Index cases N=1,840) vs. 34.75% (readmitted N=1,064/Index cases N=3,062) for the non-revascularization group (P <0.0001). Baseline characteristics of MMD with revascularization were mean age (Mean±SE) 41±0.6 vs. 40±0.5 (P=0.20), Charlson comorbidity index (CCI) 1.6±0.04 vs. 1.8±0.05 (P=0.0004), female: male 3:1. Cause-specific readmission rate in both groups was reported as per table.

Conclusion: Our analysis shows that patients treated with revascularization had significantly fewer 90-day readmissions when compared to untreated patients. MMD and ischemic stroke were the top reasons for readmission within the 90 days of discharge for both groups. A seizure was reported higher in the treatment group.

Abstract WP401: Burden of Intracranial Hemorrhage in Patients With Reversible Cerebral Vasoconstriction Syndrome

Introduction: Reversible Cerebral Vasoconstriction Syndrome (RCVS) is described as reversible constriction of cerebral arteries, presenting with severe headaches and associated with hemorrhagic or ischemic strokes. There is a dearth of the literature on demographics and risk factors associated with intracranial hemorrhage (ICH) in patients with RCVS in the US.

Methods: All patients with a primary or secondary diagnosis of RCVS in 2016 Nationwide Readmission Database (NRD) using ICD-10 code I67.841 after excluding cerebral angiitis (N=57). Unique patients were included using a unique patient identifier. Weighted discharges were used to generate national estimates. ICH was defined as both intraparenchymal and subarachnoid hemorrhage. A multivariable logistic model was used to identify ICH predictors.

Results: Among total 1,152 RCVS patients, 25.7% (296) patients developed ICH. Patients with ICH mean age was (years) (Mean±SE) 47.8 ±1.2 vs. 47.0±1.1 (P=0.62), female 85.4% vs. 78.0% (P=0.06), longer inpatient LOS 12.1±0.9 vs. 6.4±0.5 days (P<0.0001) and higher inpatient cost 42,638±4,451 vs. 18,199±1,117 (P=0.018). After multivariable analysis, two independent predictors of ICH were identified: increasing age (OR 1.02, 95% CI: 1.01-1.04, P=0.042) and female gender (OR 2.37, 95%CI: 1.25-4.50, P=0.009). Patients with ICH were at a greater risk of cerebral edema (OR 13.25, 95% CI: 5.10-34.43, P<0.0001) (Figure). Among disposition, 63.2% of patients with ICH were discharged home requiring no assistance and no mortality was observed.

Conclusion: This nationally representative sample suggests that increasing age and female gender were independent predictors of ICH. There is no difference in comorbidities including migraine contrary to prior literature, modifiable lifestyle risk factors and pregnancy in this cohort. Excellent outcome was observed as the majority of patients were discharged home. Higher LOS and cost were reported in ICH cohort.

Abstract TP139: Utilization and Outcomes of Extracranial-Intracranial Bypass Surgery in Adult Moyamoya Population

Introduction: The Extracranial-Intracranial bypass (EC-IC) surgery is performed to restore blood flow to the brain and prevent both hemorrhagic and ischemic strokes in Moyamoya disease (MMD) patients. There is a lack of contemporary data regarding EC-IC utilization, racial disparities, related mortality, and disability in the US.

Method: Using ICD 9-CM codes 437.5 and 39.28, MMD and EC-IC procedures were extracted from National Inpatient Sample 2005-2015. The weighted discharge was used to generate national estimates. Predictors of revascularization utilization were evaluated using multivariable logistic regression analysis to avoid confounding effect. Disability was defined as non-home discharges, after excluding mortality.

Results: Of total 24,484 admissions for MMD, 3,965 (16.2%) underwent revascularization. The mean age of revascularization patients was (SE) ~42 (0.52) years and F: M ratio of 3:1. After multivariable logistic model analysis, higher utilization rates were found in 40-59 year age group (48.3%, OR:1.29; P=0.02), who had ischemic strokes (9.2%, OR:1.38; P=0.03), and conventional cerebral angiography (30.2%, OR:1.80; P=0.001). Lower utilization rates were found in African Americans (14.9%, OR: 0.66; P=0.004), Hispanics (5.7%, OR: 0.60; P=0.03), Medicare recipients (13.6%, OR: 0.55; P=0.009), Northeast (11.5%, OR: 0.47; P= 0.003), Midwest (22.7%, OR: 0.55; P= 0.02), and South (24.8%, OR: 0.46; P=0.0002) compared to the West region. There is no utilization difference in gender female (72.4%, OR: 0.89; P=0.36). After EC-IC surgery, 79% were discharged home, 21% discharged to assistive facilities, and 0.6% died. After adjusting for hospital characteristics and associated comorbidities, lower disability (OR: 0.75; P=0.04) and the mortality rate was reported (OR: 0.80; P=0.71) among revascularization.

Conclusions: This nationally representative date within the US suggests that though there is no gender disparity in utilization of EC-IC bypass surgery, there is a significant racial and regional disparity in the utilization of the procedure. Patients undergoing revascularization had better functional outcomes. Further research is needed to identify potential predictors for underutilization in these cohorts.

Abstract WP207: Current Incidence, Epidemiological and Clinical Characteristics of Reversible Cerebral Vasoconstriction in the United States

Background: There is a paucity of contemporary data on incidence, epidemiological and clinical characteristics of reversible cerebral vasoconstriction syndrome (RCVS) in the United States. This study aimed to address these gaps in knowledge.

Method: All patients with a primary and secondary diagnosis of RCVS were identified from the 2016 National Readmissions Database (n=1,152) using International Classification of Disease-10 code I67.841. Unique patients were defined using the NRD’s unique patient identifier. Overall and sex-specific incidences of RCVS were computed by combining RCVS counts with the 2016 US census population data. RCVS comorbidities, complications and outcome were presented using descriptive statistics.

Result: The overall incidence of RCVS per million population (SE) was 4.62 (0.14) but the incidence in women 7.20 (0.24) was nearly four times that of men 1.91(0.13). Mean age (SE) was 47.2(0.9) but up to 87% of patients were < 65 years. Most common comorbidities seen in these patients were hypertension 51.7%, diabetes 19.3%, hyperlipidemia 25.4%, inflammatory disorders 20.7%, pregnancy 7.6%, postpartum 8.6%, and preeclampsia-eclampsia conditions 4.4%. Illicit drug abuse was nicotine 24.2%, cannabis 7.7%, alcohol 3.1% and cocaine 1.1%. A cerebral angiogram was documented in 25.1% of cases, and spinal tap in 16.3%. Most common associated complications included subarachnoid hemorrhage 21.3%, migraine 18.6%, ischemic stroke 14%, intracerebral hemorrhage 8.6%, epilepsy 9.3%, brain edema 7%, PRES 6.7%, and thunderclap headache 5.9%. Majority of patients were admitted to urban 88% and larger bedside hospital 60%. Majority of patients have private insurance 46% followed by Medicaid 24% and Medicare 23%. Average inpatient cost ($) was 25,135 ± 1,690.9 and length of Stay (Days) was 8.0 ± 0.4. Excellent outcomes were reported including 71% discharge to home, 14% of patients were discharged to a facility and in-hospital mortality was rare (0.4%).

Conclusion: RCVS is still rare in the US but the current incidence in women is almost four times that of men. Subarachnoid hemorrhage appears to be the most common documented comorbidity but in-hospital mortality is rare.

Abstract WP374: 30 Days Unplanned Readmission (30-DR) in Cerebral Vein Thrombosis: US National Retrospective Analysis

Introduction: Thrombosis of the cerebral veins and/or dural sinuses (CVST) results in 0.5% to 1% of all strokes. CVST has a lower mortality rate compared to arterial stroke; however it predisposes to certain complications, which lead to frequent hospital readmissions.

Objective: To study the readmission rate, reasons for readmissions and predictors of intracranial hemorrhage (ICH).

Method: Using the Nationwide Readmission Database (NRD) from 2013 -2014 patients with a primary discharge diagnosis of CVST (ICD 9 CM code: 437.6, 325, and 671.5) were identified. Their post-hospitalization course was tracked using the variable “NRD_visitlink,” and the time between re-admissions was calculated by subtracting the variable “NRD_DaysToEvent”. SAS 9.4 was used for data analysis with categorical and continuous variables tested using the Rao Scott Chi-square test and Student’s t-test, respectively. Multivariate logistic regression models were used for categorical dependent variable.

Result: A total of 3,611 (weighted) Index discharges of CVST were identified. After excluding elective readmissions, 11.32%, 17.04% and 21.81% were the observed readmission rates at 30, 90 and 180 day-follow-up periods respectively. The common causes of 30-day readmission (30-DR) were complications of the puerperium (8.76%), ICH (6.13%), migraine (4.23%), ischemic stroke (2.86%), sepsis (2.30%) and hypertensive complications (1.83%). Epilepsy related readmissions were observed only in the 90-day (1.95%) and 180-day (2.51%) follow up periods. The mean 30-DR cost was lower vs. Index admission (Mean ± SE $ 12,439±1139 vs. $ 16314±652; P value <0.0001) while the length of stay (LOS) during readmission was also lower compared to Index LOS (Mean ± SE 5.0±0.4 vs. 6.4±0.2 ;< 0.0001). After adjusting age and gender, multivariate predictors of increase risk of ICH readmission were hypertension (OR 4.79 CL 1.38-16.59; P=0.0068), primary hypercoagulable state (OR 3.34, CL 1.12-9.99; P=0.0306), meningitis (OR 17.77 CL 2.51-125.96, P=0.0041) and chronic kidney disease (OR 3.80CL 1.04-13.85, P=0.0434).

Conclusion: Puerperal complications, ICH, epilepsy and sepsis are the most common complications prompting re-hospitalization in patients diagnosed with CVST.

Comparison of angioplasty and bypass surgery for critical limb ischaemia in patients with infrapopliteal peripheral artery disease

BACKGROUND

Both infrapopliteal (IP) bypass surgery and percutaneous transluminal angioplasty have been shown to be effective in patients with critical limb ischaemia (CLI). The most appropriate method of revascularization has yet to be established, as no randomized trials have been reported. The aim of this study was to compare the outcomes of patients with similar characteristics treated using either revascularization method.

METHODS

Consecutive patients undergoing IP bypass and IP angioplasty for CLI (Rutherford 4-6) at a single institution were compared following propensity score matching. The study endpoints were primary, assisted primary and secondary patency, and amputation-free survival at 12 months, calculated by Kaplan-Meier analysis.

RESULTS

Some 279 limbs in 243 patients were included in the study. The two groups differed significantly with respect to the incidence of diabetes (P = 0·024), estimated glomerular filtration rate (P = 0·006), total lesion length (P < 0·001) and Rutherford classification (P = 0·008). These factors were used to construct the propensity score model, which yielded a matched cohort of 125 legs in each group. Primary patency (54·4 versus 51·4 per cent; P = 0·014), assisted primary patency (77·5 versus 62·7 per cent; P = 0·003), secondary patency (84·4 versus 65·8 per cent; P < 0·001) and amputation-free survival (78·7 versus 74·1 per cent; P = 0·043) were significantly better after bypass than angioplasty. However, limb salvage was similar (90·4 versus 94·2 per cent; P = 0·161), and overall complications (36·0 versus 21·6 per cent; P = 0·041) as well as length of hospital stay (18(4-134) versus 5(0-110); P = 0·001) were worse in the surgical bypass group.

CONCLUSION

There was no difference in limb salvage rates, but patency and amputation-free survival rates were better 1 year after bypass surgery.

Atherosclerotic Plaque Analysis: A Pilot Study to Assess a Novel Tool to Predict Outcome Following Lower Limb Endovascular Intervention

INTRODUCTION

Atherosclerotic plaque analysis using computed tomography angiography (CTA) has been found to be accurate and reproducible in the coronary and carotid arteries. The aim of our study was to assess the utility of this technique in predicting outcome following lower limb endovascular interventions.

METHODS

Pre-procedural CTA was retrospectively analysed in 50 patients who had undergone femoropopliteal (F-P) angioplasty (and/or stenting). Plaque analysis was performed using TeraRecon workstation by two observers blinded to the long-term outcome. Using the Hounsfield units (HU) scale atherosclerotic plaque composition was subdivided into volumes of soft (-100-100 HU) fibrocalcific (101-300 HU) or calcified (300-1000 HU) components. The relationship between plaque composition, clinical and procedural variables, and the study end points (vessel patency, binary restenosis rate, and Amputation-Free Survival [AFS]) were assessed using multivariate analysis.

RESULTS

The technical success rate of the endovascular procedure was 98%, with 48% of patients receiving F-P stents. The AFS was 90%, primary patency 84%, assisted primary patency 88%, and binary restenosis 44% all at 1 year. A significantly greater total volume of calcified plaque (1.1 [.01-3.2] cm(3) vs. .11 [0-1.86] cm(3), p < .001) was found in patients developing restenosis (>50%) compared with those who did not. Patients with a calcified plaque volume greater than 1.1 cm(3) had a significantly worse AFS than those with a volume less than 1.1 cm(3) (p = .0038). Multivariate analysis showed that the percentage calcified plaque (p = .003, HR 11.4, 95% CI 1.45-37.29) was an independent predictor of binary restenosis at 12 months, and that absolute volume of calcified plaque (p = .001, HR 3.56, 95% CI 1.64-7.7) was independently associated with AFS.

CONCLUSIONS

The burden of calcified plaque, but not soft or fibrocalcific plaque is related to restenosis, reintervention, and AFS. Computed tomography plaque analysis may form an important non-invasive tool for risk stratification in patients undergoing F-P endovascular procedures.

Hybrid revascularization of complex multilevel disease: a paradigm shift in critical limb ischemia treatment

Critical limb ischemia frequently occurs on a background of extensive co-morbidities and carries a poor prognosis which requires urgent management. Disease severity and patient comorbidity influence the initial choice of management which according to traditional paradigms, is a choice between open or endovascular repair. Over the last decade hybrid intervention, which is the planned combined use of both open and endovascular techniques, has increasingly been used to tackle multilevel disease. In this review we look at the techniques and results of hybrid surgery. This technique is ideal for multilevel lesions, as it is minimally invasive, allows prompt limb revascularization as opposed to the delays inherent in staged procedures and it appears to be more convenient to patients. It also leads to reduced length of hospital stay and reduces overall cost. Most importantly it offers an alternative to open revascularization in medically high risk patients. The success and popularity of hybrid interventions has been underpinned by advances in stent and balloon technology and the advent of the hybrid operating theatre which has allowed multiple techniques to be used simultaneously. Iliac angioplasty and stenting is now the first line of treatment for TASC C/D iliac lesions with good technical success and long-term patency. In patients who also have common femoral disease, endarterectomy can be combined with iliac stenting and this has now almost replaced open bypass. Most series for a variety of hybrid procedures report good limb salvage rates, with morbidity and mortality data considered equal to or better than open bypass procedures. Careful patient selection and detailed preoperative planning are essential to achieve these excellent results. Studies have reported on prospective series or retrospective analysis for various hybrid techniques, including non randomized trials comparing hybrid and open surgical treatment. Ideally, a randomized controlled trial comparing open and hybrid treatment is needed to minimize confounding variables.

Thyroid surgery as a 23-hour stay procedure

INTRODUCTION

The main barriers to short stay thyroidectomy are haemorrhage, bilateral recurrent laryngeal nerve palsy causing respiratory compromise and hypocalcaemia. This study assessed the safety and effectiveness of thyroidectomy as a 23-hour stay procedure.

METHODS

All patients undergoing total or completion thyroidectomy were prescribed calcium and vitamin D3 supplements following surgery. Retrospective analysis identified patients admitted for longer than 23 hours and any readmissions.

RESULTS

A total of 164 patients were admitted for 23-hour stay thyroid surgery over a 25-month period between 2008 and 2010. Four patients (2%) required admission for longer than 23 hours. No patients required emergency intervention for postoperative haemorrhage or airway compromise. Biochemical hypocalcaemia (despite calcium supplements) was detected in one patient when measured at the outpatient clinic two weeks following surgery. Twelve patients (7.3%) attended the accident and emergency department following discharge; four required admission for intravenous antibiotics for wound infection and one for biochemical hypocalcaemia.

CONCLUSIONS

This single centre UK experience demonstrates that thyroidectomy can be carried out both safely and effectively as a 23-hour stay procedure. Prophylactic prescription of calcium and vitamin D3 reduces hypocalcaemia, and thereby also prolonged admission and readmission due to hypocalcaemia. Supplements are an acceptable, cost effective method of reducing hypocalcaemia and shortening postoperative length of stay.

Convergent functional genomics of schizophrenia: from comprehensive understanding to genetic risk prediction

We have used a translational convergent functional genomics (CFG) approach to identify and prioritize genes involved in schizophrenia, by gene-level integration of genome-wide association study data with other genetic and gene expression studies in humans and animal models. Using this polyevidence scoring and pathway analyses, we identify top genes (DISC1, TCF4, MBP, MOBP, NCAM1, NRCAM, NDUFV2, RAB18, as well as ADCYAP1, BDNF, CNR1, COMT, DRD2, DTNBP1, GAD1, GRIA1, GRIN2B, HTR2A, NRG1, RELN, SNAP-25, TNIK), brain development, myelination, cell adhesion, glutamate receptor signaling, G-protein-coupled receptor signaling and cAMP-mediated signaling as key to pathophysiology and as targets for therapeutic intervention. Overall, the data are consistent with a model of disrupted connectivity in schizophrenia, resulting from the effects of neurodevelopmental environmental stress on a background of genetic vulnerability. In addition, we show how the top candidate genes identified by CFG can be used to generate a genetic risk prediction score (GRPS) to aid schizophrenia diagnostics, with predictive ability in independent cohorts. The GRPS also differentiates classic age of onset schizophrenia from early onset and late-onset disease. We also show, in three independent cohorts, two European American and one African American, increasing overlap, reproducibility and consistency of findings from single-nucleotide polymorphisms to genes, then genes prioritized by CFG, and ultimately at the level of biological pathways and mechanisms. Finally, we compared our top candidate genes for schizophrenia from this analysis with top candidate genes for bipolar disorder and anxiety disorders from previous CFG analyses conducted by us, as well as findings from the fields of autism and Alzheimer. Overall, our work maps the genomic and biological landscape for schizophrenia, providing leads towards a better understanding of illness, diagnostics and therapeutics. It also reveals the significant genetic overlap with other major psychiatric disorder domains, suggesting the need for improved nosology.

Pharmacokinetics of gatifloxacin in broiler chickens following intravenous and oral administration

1. The pharmacokinetics of gatifloxacin were investigated following intravenous and oral administration of a single dose at a rate of 10 mg/kg body weight in broiler chicks. 2. Drug concentration in plasma was determined using High Performance Liquid Chromatography with ultraviolet detection on samples collected at frequent intervals after drug administration. 3. Following intravenous administration, the drug was rapidly distributed (t(1/2α): 0·33 ± 0·008 h) and eliminated (t(1/2β): 3·62 ± 0·03 h; Cl(B): 0·48 ± 0·002 l/h/kg) from the body. 4. After oral administration, the drug was rapidly absorbed (C (max): 1·74 ± 0·024 µg/mL; T (max): 2 h) and slowly eliminated (t(1/2β): 3·81 ± 0·07 h) from the body. The apparent volume of distribution (V(d(area))), total body clearance (Cl(B)) and mean residence time (MRT) were 3·61 ± 0·04 l/kg, 0·66 ± 0·01 l/h/kg and 7·16 ± 0·08 h, respectively. The oral bioavailability of gatifloxacin was 72·96 ± 1·10 %. 5. Oral administration of gatifloxacin at 10 mg/kg is likely to be highly efficacious against susceptible bacteria in broiler chickens.

Case report. A novel approach to the management of a ruptured Type II endoleak following endovascular repair of an internal iliac artery aneurysm

Endovascular repair of isolated iliac artery aneurysms is an established safe and effective management option. Type II endoleak is a potential complication, but rarely results in significant morbidity or mortality. We report a case of a patient who presented with a ruptured internal iliac artery aneurysm secondary to a Type II endoleak. To our knowledge this and the following method of managing this have not been previously reported. Established methods of managing endoleaks, such as intravascular transfemoral embolisation and open or laparoscopic ligation, were not possible. Therefore, we resorted to a novel approach to this type of aneurysm and successfully performed a transcutaneous direct puncture and embolisation of the superior gluteal artery.

Convergent functional genomics of anxiety disorders: translational identification of genes, biomarkers, pathways and mechanisms

Anxiety disorders are prevalent and disabling yet understudied from a genetic standpoint, compared with other major psychiatric disorders such as bipolar disorder and schizophrenia. The fact that they are more common, diverse and perceived as embedded in normal life may explain this relative oversight. In addition, as for other psychiatric disorders, there are technical challenges related to the identification and validation of candidate genes and peripheral biomarkers. Human studies, particularly genetic ones, are susceptible to the issue of being underpowered, because of genetic heterogeneity, the effect of variable environmental exposure on gene expression, and difficulty of accrual of large, well phenotyped cohorts. Animal model gene expression studies, in a genetically homogeneous and experimentally tractable setting, can avoid artifacts and provide sensitivity of detection. Subsequent translational integration of the animal model datasets with human genetic and gene expression datasets can ensure cross-validatory power and specificity for illness. We have used a pharmacogenomic mouse model (involving treatments with an anxiogenic drug--yohimbine, and an anti-anxiety drug--diazepam) as a discovery engine for identification of anxiety candidate genes as well as potential blood biomarkers. Gene expression changes in key brain regions for anxiety (prefrontal cortex, amygdala and hippocampus) and blood were analyzed using a convergent functional genomics (CFG) approach, which integrates our new data with published human and animal model data, as a translational strategy of cross-matching and prioritizing findings. Our work identifies top candidate genes (such as FOS, GABBR1, NR4A2, DRD1, ADORA2A, QKI, RGS2, PTGDS, HSPA1B, DYNLL2, CCKBR and DBP), brain-blood biomarkers (such as FOS, QKI and HSPA1B), pathways (such as cAMP signaling) and mechanisms for anxiety disorders--notably signal transduction and reactivity to environment, with a prominent role for the hippocampus. Overall, this work complements our previous similar work (on bipolar mood disorders and schizophrenia) conducted over the last decade. It concludes our programmatic first pass mapping of the genomic landscape of the triad of major psychiatric disorder domains using CFG, and permitted us to uncover the significant genetic overlap between anxiety and these other major psychiatric disorders, notably the under-appreciated overlap with schizophrenia. PDE10A, TAC1 and other genes uncovered by our work provide a molecular basis for the frequently observed clinical co-morbidity and interdependence between anxiety and other major psychiatric disorders, and suggest schizo-anxiety as a possible new nosological domain.

Convergent functional genomic studies of ω-3 fatty acids in stress reactivity, bipolar disorder and alcoholism

Omega-3 fatty acids have been proposed as an adjuvant treatment option in psychiatric disorders. Given their other health benefits and their relative lack of toxicity, teratogenicity and side effects, they may be particularly useful in children and in females of child-bearing age, especially during pregnancy and postpartum. A comprehensive mechanistic understanding of their effects is needed. Here we report translational studies demonstrating the phenotypic normalization and gene expression effects of dietary omega-3 fatty acids, specifically docosahexaenoic acid (DHA), in a stress-reactive knockout mouse model of bipolar disorder and co-morbid alcoholism, using a bioinformatic convergent functional genomics approach integrating animal model and human data to prioritize disease-relevant genes. Additionally, to validate at a behavioral level the novel observed effects on decreasing alcohol consumption, we also tested the effects of DHA in an independent animal model, alcohol-preferring (P) rats, a well-established animal model of alcoholism. Our studies uncover sex differences, brain region-specific effects and blood biomarkers that may underpin the effects of DHA. Of note, DHA modulates some of the same genes targeted by current psychotropic medications, as well as increases myelin-related gene expression. Myelin-related gene expression decrease is a common, if nonspecific, denominator of neuropsychiatric disorders. In conclusion, our work supports the potential utility of omega-3 fatty acids, specifically DHA, for a spectrum of psychiatric disorders such as stress disorders, bipolar disorder, alcoholism and beyond.

Identification of blood biomarkers for psychosis using convergent functional genomics

There are to date no objective clinical laboratory blood tests for psychotic disease states. We provide proof of principle for a convergent functional genomics (CFG) approach to help identify and prioritize blood biomarkers for two key psychotic symptoms, one sensory (hallucinations) and one cognitive (delusions). We used gene expression profiling in whole blood samples from patients with schizophrenia and related disorders, with phenotypic information collected at the time of blood draw, then cross-matched the data with other human and animal model lines of evidence. Topping our list of candidate blood biomarkers for hallucinations, we have four genes decreased in expression in high hallucinations states (Fn1, Rhobtb3, Aldh1l1, Mpp3), and three genes increased in high hallucinations states (Arhgef9, Phlda1, S100a6). All of these genes have prior evidence of differential expression in schizophrenia patients. At the top of our list of candidate blood biomarkers for delusions, we have 15 genes decreased in expression in high delusions states (such as Drd2, Apoe, Scamp1, Fn1, Idh1, Aldh1l1), and 16 genes increased in high delusions states (such as Nrg1, Egr1, Pvalb, Dctn1, Nmt1, Tob2). Twenty-five of these genes have prior evidence of differential expression in schizophrenia patients. Predictive scores, based on panels of top candidate biomarkers, show good sensitivity and negative predictive value for detecting high psychosis states in the original cohort as well as in three additional cohorts. These results have implications for the development of objective laboratory tests to measure illness severity and response to treatment in devastating disorders such as schizophrenia.

Coming to grips with complex disorders: genetic risk prediction in bipolar disorder using panels of genes identified through convergent functional genomics

We previously proposed and provided proof of principle for the use of a complementary approach, convergent functional genomics (CFG), combining gene expression and genetic data, from human and animal model studies, as a way of mining the existing GWAS datasets for signals that are there already, but did not reach significance using a genetics-only approach [Le-Niculescu et al., 2009b]. CFG provides a fit-to-disease prioritization of genes that leads to generalizability in independent cohorts, and counterbalances the fit-to-cohort prioritization inherent in classic genetic-only approaches, which have been plagued by poor reproducibility across cohorts. We have now extended our previous work to include more datasets of GWAS, and more recent evidence from other lines of work. In essence our analysis is the most comprehensive integration of genetics and functional genomics to date in the field of bipolar disorder. Biological pathway analyses identified top canonical pathways, and epistatic interaction testing inside these pathways has identified genes that merit future follow-up as direct interactors (intra-pathway epistasis, INPEP). Moreover, we have put together a panel of best P-value single nucleotide polymorphisms (SNPs), based on the top candidate genes we identified. We have developed a genetic risk prediction score (GRPS) based on our panel, and demonstrate how in two independent test cohorts the GRPS differentiates between subjects with bipolar disorder and normal controls, in both European-American and African-American populations. Lastly, we describe a prototype of how such testing could be used to categorize disease risk in individuals and aid personalized medicine approaches, in psychiatry and beyond.

Convergent functional genomics of genome-wide association data for bipolar disorder: comprehensive identification of candidate genes, pathways and mechanisms

Given the mounting convergent evidence implicating many more genes in complex disorders such as bipolar disorder than the small number identified unambiguously by the first-generation Genome-Wide Association studies (GWAS) to date, there is a strong need for improvements in methodology. One strategy is to include in the next generation GWAS larger numbers of subjects, and/or to pool independent studies into meta-analyses. We propose and provide proof of principle for the use of a complementary approach, convergent functional genomics (CFG), as a way of mining the existing GWAS datasets for signals that are there already, but did not reach significance using a genetics-only approach. With the CFG approach, the integration of genetics with genomics, of human and animal model data, and of multiple independent lines of evidence converging on the same genes offers a way of extracting signal from noise and prioritizing candidates. In essence our analysis is the most comprehensive integration of genetics and functional genomics to date in the field of bipolar disorder, yielding a series of novel (such as Klf12, Aldh1a1, A2bp1, Ak3l1, Rorb, Rora) and previously known (such as Bdnf, Arntl, Gsk3b, Disc1, Nrg1, Htr2a) candidate genes, blood biomarkers, as well as a comprehensive identification of pathways and mechanisms. These become prime targets for hypothesis driven follow-up studies, new drug development and personalized medicine approaches.

Identifying blood biomarkers for mood disorders using convergent functional genomics

There are to date no objective clinical laboratory blood tests for mood disorders. The current reliance on patient self-report of symptom severity and on the clinicians' impression is a rate-limiting step in effective treatment and new drug development. We propose, and provide proof of principle for, an approach to help identify blood biomarkers for mood state. We measured whole-genome gene expression differences in blood samples from subjects with bipolar disorder that had low mood vs those that had high mood at the time of the blood draw, and separately, changes in gene expression in brain and blood of a mouse pharmacogenomic model. We then integrated our human blood gene expression data with animal model gene expression data, human genetic linkage/association data and human postmortem brain data, an approach called convergent functional genomics, as a Bayesian strategy for cross-validating and prioritizing findings. Topping our list of candidate blood biomarker genes we have five genes involved in myelination (Mbp, Edg2, Mag, Pmp22 and Ugt8), and six genes involved in growth factor signaling (Fgfr1, Fzd3, Erbb3, Igfbp4, Igfbp6 and Ptprm). All of these genes have prior evidence of differential expression in human postmortem brains from mood disorder subjects. A predictive score developed based on a panel of 10 top candidate biomarkers (five for high mood and five for low mood) shows sensitivity and specificity for high mood and low mood states, in two independent cohorts. Our studies suggest that blood biomarkers may offer an unexpectedly informative window into brain functioning and disease state.

Glutamine deprivation facilitates tumour necrosis factor induced bacterial translocation in Caco-2 cells by depletion of enterocyte fuel substrate

BACKGROUND AND AIMS

Factors that induce luminal bacteria to cross the intestinal epithelium following injury remain poorly defined. The aim of this study was to investigate the interaction between glutamine metabolism, energy supply, and inflammatory mediators in determining the translocation of non-pathogenic bacteria across cultured enterocytes.

METHODS

The effect of tumour necrosis factor alpha (TNF-alpha) on translocation of Escherichia coli C25 across Caco-2 epithelial monolayers was studied in the presence of products and inhibitors of glutamine metabolism. Simultaneous measurements of transepithelial electrical resistance (TEER) and flux of lucifer yellow were used to assess effects on the paracellular pathway. Lactate dehydrogenase release was used to monitor enterocyte integrity. Imaging of monolayers in these experimental conditions was undertaken with transmission electron microscopy.

RESULTS

Exposure to basolateral TNF-alpha (20 ng/ml) for six hours induced translocation of E coli across Caco-2 but only if accompanied by simultaneous glutamine depletion (p<0.01). Translocation was inhibited by addition of glutamine for two hours (p<0.01) but not by an isonitrogenous mixture of non-glutamine containing amino acids. Inhibition of glutamine conversion to alpha-ketoglutarate, but not blockade of glutathione or polyamine synthesis, also induced translocation in the presence of TNF-alpha. Manipulations that induced bacterial translocation were associated with a marked reduction in enterocyte ATP levels. No effect of these treatments on paracellular permeability or lactate dehydrogenase release was observed. Conditions in which translocation occurred were associated with the presence of bacteria within enterocyte vacuoles but not the paracellular space.

CONCLUSIONS

In inflammatory conditions, the availability of glutamine as an enterocyte fuel substrate is essential for the preservation of a functional barrier to microorganisms. In conditions of acute glutamine depletion, cytokine mediated bacterial translocation appears to be primarily a transcellular process.

Cell density-dependent proliferation in frequently-fed peripheral blood mononuclear cell cultures

BACKGROUND

Our goal was to produce granulocyte progenitor (CFU-G) and post-progenitor (CD15(+)CD11b(+/-)) cells for subsequent transplantation. We hypothesized that increasing the feeding frequency and maintaining constant densities may overcome inhibitory growth conditions (i.e. low pH) in high-density cultures.

METHODS

To study the effect of cell density on total cell expansion, differentiation and lactate production, 50% daily medium exchanges were used in cultures of peripheral blood mononuclear cells (PB MNC) maintained at constant densities (ranging from 5 x 10(4)cells/mL to 2.5 x 10(6)cells/mL).

RESULTS

We observed a significant increase in total cell expansion when the density was increased from 5 x 10(4) cells/mL to 1 x 10(6) cells/mL, but a further increase to 2.5 x 10(6)cells/mL resulted in a decline in cell expansion. Increasing feeding to 90% daily exchange in cultures with 2.5 x 10(6) cells/mL did not enhance cell expansion; nor did reducing the extent of feeding in cultures with 5 x 10(4) cells/mL to 10% daily exchange. We did not observe a relationship between cell density and the percentage of granulocyte progenitor and post-progenitor (CD15(+)CD11b(-/+)) cells. While specific lactate production (q(lac)) in cultures with 2.5 x 10(6) cells/mL was approximately 60% of those observed in lower density cultures by Day 13, this difference was largely eliminated by increasing the extent of feeding in cultures with 2.5 x 10(6) cells/mL.

DISCUSSION

Our results suggest that feeding rates must be adjusted according to cell density to maximize culture performance. They also suggest that cellular crowding on the culture surface can limit expansion in suspension (nonadherent) cultures.

Clinical-scale production of granulocyte progenitor and post-progenitor cells using daniplestim, leridistim, Progenipoietin, Promegapoietin and autologous plasma

BACKGROUND

Supplementation of PBPC autografts with ex vivo expanded PBMC may significantly reduce or eliminate the period of neutropenia associated with high-dose chemotherapy.

METHODS

Unmanipulated growth-factor mobilized PBMC were expanded in media containing daniplestim, leridistim, Promegapoietin, and Progenipoietin (DLPP) and 2% autologous plasma at 4 x 10(5) PBMC/mL, first in 25 cm(2) T-flasks, with sampling on Days 7, 10, 13 and 15, and then in 1264 cm(2) Nunclon Cell Factories, with sampling on Days 7 and 13.

RESULTS

In T25-flasks, maximal CFU-GM expansion ([38.2 +/- 9.5]-fold) occurred on Day 10, whereas maximal total cell expansion ([6.7 +/- 1.1]-fold) occurred on Day 15. Production of CD15(+)CD11b(-) and CD15(+)CD11b(+) granulocytic post-progenitors (3.0 +/- 0.4 x 10(6) and 3.7 +/- 0.9 x 10(6), respectively) was also maximal at Day 15. Compared with the previously studied combination of Flt3L, PIXY321, G-CSF, GM-CSF and Epo, the DLPP cocktail performed similarly, with the exception of yielding larger GM colonies at Day 10 and fewer granulocyte post-progenitors on Day 15. In Cell Factories, CFU-GM were expanded (31.6 +/- 14.5)-fold, while total nonadherent cells were expanded (2.6 +/- 0.5)-fold. The two stack Cell Factory cultures seeded with 1.0 x 10(8) unselected PBMC produced approximately 3.3 x 10(6) CFU-GM and 1.3 x 10(8) myeloid post-progenitors.

DISCUSSION

Whereas expansion of cell numbers, CFU-GM and granulocytic post-progenitors in Cell Factories mirrored that achieved in T25-flasks, future preclinical studies with the DLPP cytokine combination may be performed in small volumes, with subsequent translation to the larger volume Cell Factories. Sufficient expansion can be achieved using the DLPP cytokine combination in the Cell Factories to provide the numbers of progenitors required for clinical trials.

Selection of zinc fingers that bind single-stranded telomeric DNA in the G-quadruplex conformation

There is considerable interest in molecules that bind to telomeric DNA sequences and G-quadruplexes with specificity. Such molecules would be useful to test hypotheses for telomere length regulation, and may have therapeutic potential. The versatility and modular nature of the zinc finger motif makes it an ideal candidate for engineering G-quadruplex-binding proteins. Phage display technology has previously been widely used to screen libraries of zinc fingers for binding to novel duplex DNA sequences. In this study, a three-finger library has been screened for clones that bind to an oligonucleotide containing the human telomeric repeat sequence folded in the G-quadruplex conformation. The selected clones show a strong amino acid consensus, suggesting analogous modes of binding. Binding was found to be both sequence dependent and structure specific. This is the first example of an engineered protein that binds to G-quadruplex DNA, and represents a new type of binding interaction for a zinc finger protein.

Anti-Tumor CC49-zeta CD4 T cells possess both cytolytic and helper functions

The authors report that the nature of the T-cell-receptor--derived signal in normal CD4+ T cells can induce interleukin-2 (IL-2) secretion or perforin-mediated cytolytic activity. Normal human T cells were genetically modified to express the tumor antigen specific chimeric immune receptor, CC49-zeta. The CC49-zeta chimeric immune receptor is comprised of the intracellular signaling domains of the TCR CD3zeta protein fused to the single chain scFv of the humanized CC49 antibody, which binds the pan-adenocarcinoma tumor antigen TAG-72. Patient-specific T cells genetically modified to express the CC49-zeta receptor have been used in patients with colon cancer. The authors report that both CD4 and CD8 T cells expressing the CC49-zeta receptor mediated the major histocompatibility complex-unrestricted lysis of TAG-72--expressing tumor cells with comparable efficiency. However, although the CC49-zeta receptor mediated target cell lysis, it did not support the production of IL-2, even in the presence of CD28 stimulation. Robust IL-2 secretion and T-cell proliferation were observed when the same CD4 CC49-zeta T cells were stimulated through the CD28 receptor and endogenous T-cell receptor. These results indicate that CD4 T lymphocytes possess the capacity to act as both cytolytic and helper T cells and that this difference in effector function is controlled by the nature of the T-Cell receptor--derived signals.